Successful treatment with noninvasive positive-pressure ventilation based on the prediction of disease onset using CT and respiratory function tests in an elderly patient with relapsing polychondritis

[Tracheobronchial involvement in relapsing polychondritis and differential diagnoses]

Relapsing polychondritis is a systemic auto-immune disease that mainly affects cartilage structures, progressing through inflammatory flare-ups between phases of remission and ultimately leading to deformation of the cartilages involved. In addition to characteristic damage of auricular or nasal cartilage, tracheobronchial and cardiac involvement are particularly severe, and can seriously alter the prognosis. Tracheobronchial lesions are assessed by means of a multimodal approach, including dynamic thoracic imaging, measurement of pulmonary function (with recent emphasis on pulse oscillometry), and mapping of tracheal lesions through flexible bronchoscopy. Diagnosis can be difficult in the absence of specific diagnostic tools, especially as there may exist a large number of differential diagnoses, particularly as regards inflammatory diseases. The prognosis has improved, due largely to upgraded interventional bronchoscopy techniques and the development of immunosuppressant drugs and targeted therapies, offering patients a number of treatment options.

Evaluation of airway involvement and treatment in patients with relapsing polychondritis

Airway involvement in relapsing polychondritis (RP) can be debilitating and life threatening, often requiring interventional procedures. If standard therapies including systemic corticosteroid and immunosuppressive agents are ineffective, airway stenting is often required. Recently, biologics have been reported to be effective for RP, and the early administration of biologics may avoid airway stenting. To evaluate survival rates and treatment approaches, medical records of RP patients with airway involvement were reviewed. These cases were divided into the following groups: with and without malacia, stenting and non-stenting, and with and without biologics. Kaplan-Meier was used to calculate survival rates and log rank tests were used to analyze biologics groups. A total of 77 patients were enrolled. Airway stenting was performed in 13 patients, all of which developed airway malacia. The stenting group had significantly lower survival rates than the non-stenting group (p < 0.001). Stent-related complications were granulation tissue (85%) and mucostasis (69%). In the non-stenting group, a lower mortality rate was observed. A significantly higher survival rate was seen in patients administered biologics than without (p = 0.014). The early administration of biologics shows promise in preventing severe airway disorders that require airway stenting.

Recurrent polychondritis: a review of the literature and a clinical case description

Relapsing polychondritis (RPC) is a rare disease, its diagnosis presents certain difficulties. This is due to the absence of characteristic clinical manifestations at the initial stages of the disease, late diagnosis and difficulties in selecting adequate therapy.The article presents a review of the literature on the diagnosis and treatment of RPC, as well as a clinical case with tracheobronchial tree and other organ systems involvement in the absence of classical auricular involvement.

Long-Term Outcome of Metallic Stenting for Central Airway Involvement in Relapsing Polychondritis

BACKGROUND

Placement of uncovered self-expandable metallic stents was found to successfully alleviate critical airflow limitation in patients with relapsing polychondritis (RP) with central airway involvement by several reports. However, the long-term outcome of airway metallic stenting in patients with RP remain unclear.

METHODS

We retrospectively analyzed patients with RP who underwent airway metallic stenting with the use of fiberoptic bronchoscopy between September 1, 2009, and October 1, 2017, in Shanghai. Outcome measurements, including modified Medical Research Council (mMRC) dyspnea score, 6-minute walk distance (6MWD), spirometry, and bronchoscopic findings, as well as adverse events after stent placement, were collected.

RESULTS

A total of 27 patients were included; the median patient age was 58 years (range: 41 to 74 years), and 19 were men (70.4%). Nineteen uncovered self-expandable metallic stents were placed in the trachea and 39 in the main bronchi. The median follow-up time was 50.5 months (range: 6 to 100 months). The baseline forced expiratory volume in 1 second (FEV₁) percentage predicted (%pred), FEV₁/forced vital capacity (FVC), and peak expiratory flow (PEF) was 24.2 ± 3.7, 27.2 ± 5.6, and 0.99 ± 0.21 L/min, respectively. One day after the procedure, improvement from baseline in FEV₁ %pred, FEV₁/FVC, and PEF was 17.9 ± 8.9 (p = 0.001), 19.8 ± 10.9 (p = 0.002), and 0.69 ± 0.44 L/min (p = 0.001), respectively. Changes in the following variables were also statistically and clinically significant: 6MWD of 193.7 ± 83.4 m; mMRC dyspnea score of -1.2 ± 0.4 points (both p < 0.05). The improvements were maintained at 5 years: a mean change in FEV₁ %pred, FEV₁/FVC, PEF, 6MWD, and mMRC score was 19.5 ± 6.7, 13.9 ± 5.0, 0.82 ± 0.40 L/min, 134.7 ± 66.2 m, and -0.83 ± 0.29 points, respectively. Cough, foreign body sensation, mucus production, and granulomas were common adverse events, occurring in 48.1% (13 of 27), 40.7% (11 of 27), 29.6% (8 of 27), and 25.9% (7 of 27) of the subjects. However, none of those complications were severe enough to require urgent bronchoscopic interventions.

CONCLUSIONS

Airway metallic stenting in patients with RP with central airway involvement resulted in long-term clinical benefits in lung function, exercise tolerance, and dyspnea with an acceptable safety profile.

Relapsing polychondritis: a clinical review for rheumatologists

Relapsing polychondritis (RPC) is a rare autoimmune rheumatic disorder that is traditionally classified as a systemic vasculitis. It is characterized by inflammation of cartilage, and typical presenting features include chondritis of the nasal bridge, auricular chondritis, ocular inflammation and involvement of the bronchial tree. Its rarity often leads to considerable delay in establishing a diagnosis and poses a significant management challenge to clinicians, as no conventional guidelines exist. This review summarizes the clinical features of RPC and provides guidance for rheumatologists on making the diagnosis and assessing organ involvement. The current state of RPC management is reviewed, with a focus on the use of the anti-TNF-α agents in patients with pulmonary involvement, the leading cause of mortality and morbidity in RPC.